Health History FormThis health history/consent form is personal and confidential. Thank you for taking the time for yourself today. Name * First Name Last Name Email * Message * Phone Number * Date of Birth Height/Weight Referred By Any concerns about or recovery from: Drugs, alcohol, sex, electronic devices, codependency or other? Do you eat breakfast? How long after waking do you eat breakfast? Are you currently under the care of MD, Chiropractor, Acupuncturist Therapist? What medications have you taken in the last 6 months? List any past injuries, illness, accidents, trauma: Any chronic bodily discomfort, emotional/spiritual concerns? Please list any past surgeries: Previous coaching experience? Kindly note: There is a 24 hour cancellation policy for all appointments. By typing my name, I grant consent. * Thank you and kindly note that there is a 24 hour cancellation policy for all appointments.